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A 47-year-old woman with DOE

A 47-year-old woman with DOE. Prev.healthy 7 개월 전부터 alopecia 발생 , DOE 발생 (GrII), 6 개월 전 skin lesion (both elbow area 에 rash) 발생 . local 의원 내원하여 topical stroid apply 5 개월 전 skin rash & arthralgia (both wrist) 증상으로 동대 한방 병원 내원하여 한약 복용하였으나 , 증상 호전 없음 .

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A 47-year-old woman with DOE

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  1. A 47-year-old woman with DOE • Prev.healthy • 7개월 전부터 alopecia 발생, DOE 발생 (GrII), • 6개월 전 skin lesion (both elbow area에 rash) 발생. local 의원 내원하여 topical stroid apply • 5개월 전 skin rash & arthralgia (both wrist) 증상으로 동대 한방 병원 내원하여 한약 복용하였으나, 증상 호전 없음. • 4개월 전 DOE 악화 (GrIII), 손마디에도 갈색 반점 발생. 밤마다 febrile sense 동반, both arm weakness, 1st MTP jt pain 심해짐 • 3개월 전 OS병원 경유하여, local 류마치스 내과 내원하여, medication.(소론도, MTX, 조피린, 나벤탁, 알소벤, 라벤, 액사티딘, 폴린, 다이보넥스) 약 3-4일 복용 후 erythematous skin rash, skin itching 발생함 • 2개월 전 SMC IM9 내원하여 r/o Psoriasis, Psoriatic artropathy 로 PD 5mg qd start, 이후 skin rash 호전보임* RA(-), FANA(-), Anti-CCP Ab(-)* Skin Bx: . Hydropic degeneration of basal layer . Myxoid degeneration of deep dermal collagens • 15일 전 밤마다 febrile sense 동반되고, DOE 증상 악화 • 1주일 전 dyspnea 심해져 ER 내원.(11pm)V/S 137/91-141-42-38.6'C(SPO2 83%) -> O2 5L nasal prong 으로 94~5% 정도 유지cefepime + cipro start, Pd 1Tqd지속, 주로 밤에 38'5 정도의 fever 발생 및 낮에 호전 • 2일 전 MICU adm 후 bronchoscopy & BAL 시행 -> 8pm 경 39.8'C check • 1일 전 NIV 시행 중 saturation 저하로 intubation -> mida, morphine iv 시행 후 BP 저하로 Dopa iv start • VATs bx 시행

  2. Chest PA and left lateral

  3. Subpleural and peribronchial multifocal patchy consolidation and reticulation on the lower lung zone

  4. Subpleural and peribronchial multifocal patchy consolidation and reticulation on the lower lung zone

  5. VAT’s biopsy: diffuse interstitial and intraalveolar process

  6. Orgrnizing penumonia-like process Diffuse interstitial and intraalveolar process Intravascular fibrin thrombi Intraalveolar fibrin

  7. Diffuse interstitial fibroblastic proliferation and hyaline membrane (arrow) Diffuse alveolar damage (DAD)

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